Statement On Adolescent Pregnancy
And Childbearing Before The U.S. Senate
Subcommittee On Labor Appropriationsby Joycelyn Elders
Former U.S. Surgeon General

May 25, 1994

Chairman Harkin, Senator Specter, and members
of the Subcommittee. I am delighted to be with you today to talk about adolescent
pregnancy and childbearing and the impact it has on our young people, as well
as our society in general.

Adolescent pregnancy and childbearing--their causes and their
social and economic consequences--are among the most important domestic problems
facing our Nation. As you know, I have long been fighting to bring the necessary
attention to these problems- and to marshal the resources and the collective will
to do something about them.

Let me make this point clear -- I believe in abstinence. Every
parent I know, every teacher I know, every preacher I know - we all believe in
abstinence. It is an important component in addressing the problem we are discussing
today.

Adolescent Pregnancy and Childbearing

In the United States, one million adolescent girls--one in
ten-- become pregnant each year. More than 80 percent of these pregnancies are
unintended. Approximately 5OO,000 give birth. While the pregnancy rate for adolescents
was relatively stable through the 1980s (we have data only through 1988), the
birth rate began to rise in 1986 and has reached a level not seen since the early
1970s. more of this increase has occurred among younger adolescents; the birth
rate for 15-17 year olds increased by 27 percent between 1986 and 1991 as compared
to an 18-percent increase for 18-19 year olds.

Levels and changes in adolescent pregnancy and childbearing
depend on a number of factors. The rapid increase in adolescent sexual activity
observed during the past two decades is among the most important of these. The
proportion of adolescent girls who are sexually experienced has increased from
less than one-third to more than one-half. Most disturbingly, this increase is
sharpest for the younger adolescents--the proportion of 15 year olds who are sexually
experienced has increased five-fold since 1970--from five percent to nearly 26
percent.

Another factor we must keep in mind is the longer interval
our young people spend at risk of adolescent premarital pregnancy; over the past
century this interval has increased by about three years. This is accounted for
by two factors. The first is that young men and women become physically able to
cause or sustain a pregnancy at earlier ages than in past years. The second is
that the age at first marriage has increased, due to changes in social norms and
trends toward more years of schooling.

If there is any good news on the topic of adolescent pregnancy,
it is that although the consistent and effective use of contraceptives by sexually
active adolescents is far from adequate, adolescents have increased their use
of contraceptives somewhat and this, in turn, has kept adolescent pregnancy--rates
relatively level despite large increases in the proportion sexually active. During
the 1980s, the proportion using a contraceptive method at first intercourse increased
from 53 percent to 65 percent. When pregnancy rates are calculated for sexually
active adolescents only, the 20 percent decrease observed during the 1980s clearly
shows the effect of increased contraceptive use.

It may be possible to further increase consistent contraceptive
use by adolescents with the introduction of more "user friendly" contraceptives
such as Norplant and Depo Provera. Unfortunately, current pricing on these methods
is so high that they are simply out of reach for most adolescents. Another consideration,
especially for adolescents with multiple or serial partners, is that these and
other non-barrier methods offer no protection against STD and HIV infection.

The legalization of abortion corresponded with a decline in
adolescent birth rates during the early and mid-1970s. Abortion rates for adolescents
continued to rise during the later half of the 1970s, but have increased only
slightly since. Similarly, after the increases observed during the 1970s, the
proportion of adolescent pregnancies terminated by abortion has remained at about
40 percent since 1980.

Levels of adolescent sexual activity, contraceptive use,--
pregnancy and childbearing vary by race. Black adolescents are more likely to
be sexually active than their white counterparts, their use of contraceptives
is lower and their pregnancy and birth rates are higher. These differences have
been narrowing as most of the increase in sexual activity, pregnancy and childbearing
has been for white adolescents. Nevertheless, the adverse consequences of adolescent
childbearing fall disproportionately on black women.

Thus far, I have been discussing adolescent pregnancy in terms
of numbers and trends, but there are other aspects. The social and economic costs
of premature parenthood are enormous. Adolescent childbearing has long been associated
with reduced educational attainment and employment opportunities. In turn, poverty
and AFDC dependency are more prevalent in families begun by adolescents, particularly
those that are unmarried. In 1992, an estimated $34 billion was expended on AFDC,
Medicaid, and Food Stamps for families begun by adolescents. Moreover, the children
of adolescent parents are more likely to become adolescent parents themselves,
perpetuating the cycle.

Other social factors must also be considered as having an effect
on adolescent sexual and fertility related behavior. Today, some believe that
too many adolescent pregnancies and births are intended, or at least that the
adolescent is indifferent when an unplanned pregnancy occurs. When life opportunities
are-limited, an early unplanned pregnancy may not be viewed as an obstacle to
success and a child may be considered an asset to someone who lacks hope for the
future. A family background of low educational attainment, low-income or welfare
dependency may be more a predictor of early parenthood than a consequence of it.

Comparing the U.S. Experience With Other Countries

When adolescent birth rates in the U.S. are compared with those
for Western European countries similar in culture and level of economic development,
it is clear that U.S. rates are substantially higher. Induced abortion rates for
adolescents and, by extension, pregnancy rates follow the same pattern. Levels
of sexual activity, however, are very similar.

In Western Europe, governments have recognized the need for
adolescent contraceptive services and have acted accordingly. Contraceptive services
tend to be more accessible to adolescents, as well as confidential and low cost.
In some cases, there are clinics set up specifically for adolescents and young
adults.

While comprehensive sexuality education in Western European
schools is not universal (except in Sweden), the mass media, either controlled
by or in cooperation with government, has widely disseminated information about
contraception and responsible sexual practices.

Superior access to services and education appears to translate
into higher contraceptive use for European adolescents when compared to those
in the U.S. While the United States may not choose to adopt these policies wholesale,
we can learn from the Western European experience. It seems fairly clear that
sexuality education, access to contraceptive services, and responsible treatment
of sexuality by the media can increase contraceptive use by adolescents, and that
this increased use can result in lower rates of too early pregnancy, abortion
and childbearing.

Successful Interventions

Attempts to prevent adolescent pregnancy have taken several
different forms--sexuality education, abstinence education, life skills education,
contraceptive education and contraceptive services programs--both singly and in
combination. Evaluations of these programs indicate those that combine education
with information about, or access to, contraceptive services show the most promise
of success in both delaying onset of sexual activity and preventing unplanned
pregnancies.

Beginning in the 1980s, the primary Federal focus on adolescent
pregnancy prevention was abstinence education. Delay of first intercourse is important
because an older age is positively associated with more stable relationships,
fewer partners, and an increased likelihood of contraceptive use. Where first
intercourse occurs early, contraceptive use is less likely and pregnancy risk
higher. However, information about--and for older adolescents, access to--contraceptives
is an essential component of any program developed to effectively reduce adolescent
pregnancy.

The Postponing Sexual Involvement curriculum, developed at
Emory University and the Reducing the Risk curriculum, developed by ETR Associates,
combine sexuality education, including delaying sexual involvement, social skills
training and practice in applying skills with comprehensive information about
contraceptives. These programs have shown positive effects on delaying first intercourse,
increasing the use of effective contraception at first intercourse and decreasing
the frequency of unprotected intercourse.

The success of service approaches also seems to be coupled
with other interventions such as focused educational or counseling components.
Douglas Kirby recently completed an evaluation of six school based clinics and
found that providing contraceptive services alone was not enough to increase use.
Rather, increases in contraceptive use were observed in those clinics where the
associated school had a strong educational program on prevention issues. Another
program, the Self Center, a school-linked clinic affiliated with the Johns Hopkins
University, provided medical and contraceptive services, as well as sexuality
education and individual and group counseling, to students in two nearby schools.
Evaluation results indicate that in addition to increasing contraceptive use and
decreasing pregnancy, initiation of sexual activity was delayed an average of
seven months.

Federal Programs

There are several Federal programs that provide pregnancy prevention
services but only two that focus directly on adolescent pregnancy prevention--The
Title X Family Planning Program and the Title XX Adolescent Family Life Program.

The Title X program was enacted in 1970 to provide support
for public and private nonprofit agencies in the provision of voluntary family
planning services for low-income individuals. More than 4 million clients receive
services through a network of over 4,000 clinics each year. The majority of Title
X clients are low-income women and approximately one-third are adolescents.

Rising sexual activity rates among adolescents, recent increases
in the number of adolescents and older women who need subsidized services and
concerns about prevention of sexually transmitted diseases (including HIV) have
increased the need to expand family planning services. Priority initiatives for
the Title X program include:

outreach to low-income women, adolescents and persons at high
risk of unintended pregnancy or infection with STD not now receiving family planning
services;

more emphasis on prevention of adolescent pregnancy, including
enhanced counseling as well as new service arrangement for providing services
to adolescents;

increased focus on quality and completeness of services including
treatment of STDS, screening for cervical cancer and breast cancer, substance
abuse counseling and counseling on avoidance of high risk behavior which may place
clients at risk of STD and HIV;

expansion of current clinic sites and development of clinics
in high need areas to provide services to an additional 500,000 clients per year;

more emphasis on training and retention of Family Planning
nurse practitioners and those working in clinics that serve high need populations.

The Title XX Adolescent Family Life program was enacted in
1981. The program has provided funding in three areas: (1) care demonstration
projects that serve pregnant and parenting adolescents, their infants and their
families; (2) prevention demonstration projects that provide abstinence education
services to preadolescents, adolescents and their families; and (3) research projects
on the issues of adolescent sexuality, pregnancy and childbearing.

In FY 1995 we are proposing transferring Adolescent Family
Life funds into a newly created office of Adolescent Health. The authorizing legislation
for the Office of Adolescent Health will allow us to approach adolescent health
issues from a much broader perspective than that of the Adolescent Family Life
program. Prevention of adolescent pregnancy will remain a priority but will be
approached using a broader strategy than just abstinence alone. Programs now funded
under Title XX will be eligible to compete for funds under the Office of Adolescent
Health.

Health Care Reform

Included in the President's proposed Health Security Act and
other committee markups are two components of which I am especially proud and
which are particularly pertinent to the current discussion--comprehensive school
health education and school-related health services.

The first provides authority for the development of comprehensive
health education programs in the schools. A sequential, age and developmentally
appropriate approach to school health education would provide every child with
a foundation of knowledge for risk reduction and health promoting behaviors. Ideally,
a comprehensive health education program would take an "all risk approach" and
provide prevention information on many related health topics--growth and development,
nutrition, safety, first aid, injury and violence prevention, environmental health,
tobacco and other substance abuse, disease prevention and control, mental and
emotional health, family life and human sexuality.

The second provides school-based health services. School-related
health services are logical partners of comprehensive health education in that
they can increase access to primary and preventive health care. Current proposals
target areas with the highest need as demonstrated through high rates of poverty,
adolescent pregnancy, sexually transmitted diseases, HIV infection, substance
abuse, community or gang violence and unemployment. In communities with high adolescent
pregnancy rates, there is no doubt that family planning must be a component of
these services.

Conclusion

The problems associated with adolescent childbearing are well
documented, the continued high levels of adolescent pregnancy, abortion and births
are a National embarrassment, and we know that we have done very little of real
substance to address this issue. We know it is better for our young people to
delay sexual activity and we should help them do so. We also know that when they
do become sexually active they need contraceptives to protect them against pregnancy
and STDS.

There are a number of obstacles to successful contraceptive
use by adolescents, some are related to access and some are psychological--reluctance
of adolescents to admit their sexually active status or the notion that intercourse
is more acceptable if it is spontaneous. Increasing access to contraceptive services
for adolescents is necessary, but will not be sufficient by itself. We need to
develop and implement more education and outreach efforts. By reaching adolescents
in their own environments to resolve myths and fears about sexuality and contraceptives,
as well as provide information about availability and location of services, we
can begin to reduce our disturbingly high levels of adolescent pregnancy and childbearing.

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